Breaking Bad News Badly Can Add to Upset

When the prognosis is poor, breaking the bad news badly can exacerbate the distress experienced by cancer patients and their families. A lack of sensitivity to patient and family emotions and not being attuned to how individual patients would prefer to be informed about their prognoses can result in dissatisfaction and misunderstandings, the latter possibly leading to patients continuing to receive treatment that no longer helps them or failing to receive palliative and end-of-life care. Although these findings—along with a six-step protocol known as SPIKES, for delivering bad news to patients with cancer—were reported back in 2000,1 breaking bad news continues to be a challenge for physicians and a cause for discontent among ­patients.

“Doctors could do a better job in breaking bad news,” announced the headline of a Reuters article2 about a recent German study3 that found only 46.2% of cancer patients reported being completely satisfied with how they had been told about bad news. Patients completed a questionnaire representing the six SPIKES subscales, and researchers concluded, “It could be postulated that the low satisfaction of patients observed in this study reflects the highly significant difference between patients’ preferences and bad-news delivery.”

SPIKES and Its Spinoffs

“When the prognosis is poor, oncologists can really struggle with how to phrase the information and how to give hope at the same time as being realistic,” Walter F. Baile, MD, said in an interview with The ASCO Post. Dr. Baile is Professor of Behavioral Science and Psychiatry and Director of the Interpersonal Communication and Relationship Enhancement (I*CARE) program at The University of Texas MD Anderson Cancer Center in Houston, and the lead author of the article in The Oncologist1 describing SPIKES.

The most important objectives of SPIKES are gathering information from the patient, transmitting the medical information, providing support for the patient, and eliciting the patient’s collaboration in developing a treatment strategy for the future. The six steps, according to the SPIKES acronym, are:

Setting up the interview. Prepare yourself for the interview by reviewing any test results and having a plan. Arrange for some privacy, but involve significant others. Sitting down with the patient can relax him or her and show you are not rushing through the discussion.

Perception. Use open-ended questions to assess the patient’s perception of how serious the medical condition is and whether he or she has realistic expectations of treatment.

Invitation. Ask questions to ascertain whether the patient is extending an invitation to provide full and detailed information. A patient not inviting you to tell all may delegate a friend or relative to receive that information.

Knowledge. Providing information about the patient’s prognosis might be eased by a forewarning that bad news is coming and by being clear, avoiding technical terms if you sense they might confuse the patient. Give information in manageable chunks and check to see if the patient understands. Avoid excessive bluntness.

Emotions. Address the patient’s emotions with empathic responses. Such responses also allow you to acknowledge your own sadness or other emotions, if they are ­present.

Strategy and Summary. Presenting treatment options to patients ready to receive them can allay anxiety and uncertainty, in addition to establishing shared decision-making and meeting legal mandates. This also provides an opportunity to clear up misunderstandings and “can prevent the documented tendency of patients to overestimate the efficacy or misunderstand the purpose of ­treatment.”1

Dr. Baile continued, “The fact is, breaking bad news is just one piece [of this process]. The other piece involves finding a way to support the patient and knowing how to respond to difficult questions, such as: ‘How long do I have to live? Am I going to die? If it were you, what would you do.’ So there are these spinoff responsibilities, which I think expand the necessity for a comprehensive training program, not just in the mechanics of using SPIKES, but in preparing for other aspects of giving bad news, including the doctor’s reactions,” Dr. Baile said.

“What do you do with patients you have known for a long time when you have to tell them that there is no more effective anticancer treatment, and you get sad and shed a tear, or the patient sees a tear? The focus is really on the interpersonal relationship rather than just the mechanics, because there is a back-and-forth exchange,” he added. “Well, one might say, ‘As you can see, this is tough for me to talk about.’”

Amygdala Hijacking

Another acronym, ABCDE, “emphasizes preparing yourself to give bad news,” Dr. Baile said. This includes reviewing lab results ahead of time, “so that you don’t pull them up on the computer in front of the patient and say, ‘Uh-oh’; you need to give yourself the opportunity to rehearse what you are going to say,” he added. ABCDE stands for Advance preparation, Building a relationship, Communicating well, Dealing with emotional reactions, and Empathy, Dr. Baile explained.

“In training clinicians to give bad news, another aspect we teach is the concept of amygdala hijacking,” he said. “It is a term coined by Daniel Goleman in his book, Emotional Intelligence: Why It Can Matter More Than IQ,4 and it suggests the doctor needs to be aware of the tendency to try to fix peoples’ emotions with reassurances like, ‘Things are going to be okay,’ or ‘I’ve seen lots of miracles.’”

Dr. Baile continued, “Doctors are trained to fix things, but fixing emotions usually doesn’t work, and it doesn’t sound genuine to patients. If someone cries, you don’t say, ‘Don’t cry. Everything is going to be okay.’ Better may be, ‘I can see this has really been upsetting for you.’ Goleman talks about how the doctor’s buttons can get pushed by patient emotions and lead them to say things that may not be helpful to patients. Instead letting patients know you are tuned into their feelings reinforces your relationship with them and is experienced as being ‘supportive’.”

Understanding and Recall

Dr. Baile advises physicians to make sure that patients understand the information delivered. “Just saying, ‘Did you understand’ is not enough. Better to say, ‘When you go home, tell me what you are going to tell your loved ones.’ That way, you will be sure that the information got across.”

Understanding does not guarantee, however, that patients will have accurate recall. “That’s why having a trusted significant other with the patient, whether it be a relative or partner, is so important, because that person can take notes,” Dr. Baile pointed out. In some cases, patients may signal that they don’t want to know all the details, but delegate that responsibility to significant others. In fact, this is quite common in non–Anglo-Saxon cultures.

“It is not unethical or inappropriate to not tell patients if they don’t want to know,” Dr. Baile said. In order to ensure patient understanding, sending a follow-up letter summarizing the findings discussed “is a strategy that increases patient satisfaction.”

Having patients audiotape conversations with their physicians has been shown to be helpful in returning information, Dr. Baile said, although in his experience audiotaping doesn’t happen very often. “I don’t think most oncologists would have a problem with that,” Dr. Baile said, and knowing that they are being taped actually may encourage physicians to be more clear in their explanations to patients. “Sometimes doctors get nervous when patients audiotape things because they are concerned that they may be liable for something. But as far as I know, there has never been a lawsuit based on that,” Dr. Baile said.

Practice and Role Playing

The 2000 article outlining SPIKES cited an informal study conducted at the 1998 ASCO Annual Meeting, which found that approximately 74% of those responding indicated they had to break bad news to patients at least 5 times per month, and some did so more than 20 times per month. Less than 50% of respondents, however, said they had any training in the techniques of dealing with patient’s emotions, and for most of those who did, it consisted of sitting in with a practicing clinician.

Becoming a good communicator does not just happen or result from watching others do it, according to Dr. Baile. “It is clearly a skill set that needs to be practiced. Most of the data show that if you don’t teach these kinds of skills in a way that clinicians can actually practice, with opportunities to try out different strategies, then it doesn’t stick,” he said. “It is like any other skill. If you are trying to teach someone how to do a bone marrow aspiration, you don’t tell them to read an article and then go try it on a patient.”

Teaching how to deliver bad news and deal with the questions that follow is best accomplished using role-plays—simulations of situations that present challenges when individuals interact, Dr. Baile explained. The purpose of practice and role-playing “is to practice verbal skils and create empathy for the patient. Empathy for what the other person is thinking and feeling is the gateway to effective communication skills,” he said.

“Tuning in to how the patient is feeling is very important,” he continued. “If you step into someone else’s shoes and you have a good facilitator who can immerse you in the role of that other person, then you can get a sense of what it is like to be given bad news and use that insight to guide your own communication. Part of the teaching is to also let learners hear their own words in the role of the patient. I think it is crucial in bringing them to the realization of what works [when having to break bad news] and will aid in their adopting appropriate behaviors.”

Increasing Use of Simulation

A survey conducted 8 or 9 years ago found that simulation and practice weren’t being widely used to teach how to break bad news, but that is changing, according to Dr. Baile. Communication skills constitute one of the six competencies required by the Accreditation Council for Graduate Medical Education, which strongly encourages the use of simulation methods and recognizes that physicians “need to prepare for difficult conversations and practice them in order to acquire the necessary skills,” he said.

“Here at MD Anderson we spend 12 hours a year with first-year medical oncology fellows, teaching them how to give bad news and how to respond to difficult questions. We use advanced role-play techniques called ‘action methods,’ and create enactments called stereodramas,” Dr. Baile continued. He and a colleague at MD Anderson, Daniel E. Epner, MD, described that program in articles recently published in Academic Medicine and Simulation in Healthcare.5,6

As part of the expanding interest in communication skills as a core competency, he noted that the Cleveland Clinic has dedicated itself to training every one of its staff and faculty in communication skills. “I have been working with their Institute for Healthcare Communication in training their fellows, staff, and faculty using simulation methods,” Dr. Baile noted. He also conducts such programs at other centers here and abroad, and at the time of the interview with The ASCO Post was preparing for a trip to conduct a 2-day workshop for five palliative care teams in Rome.

The National Cancer Institute and ASCO have run several training courses on these topics, and modules about breaking bad news to patients are available at several online sites, including ASCO University (university.asco.org) and the I*CARE website at MD Anderson (mdanderson.org/ICARE.) ■

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